Turkiye Klinikleri Journal of Ophthalmology

.: ORIGINAL RESEARCH
Konjonktiva Malign Melanomlarında Klinik AJCC Sınıflandırmasına Göre Tedavi Sonuçlarının Değerlendirilmesi
Evaluation of Treatment Results According to Clinical AJCC Staging in Conjunctival Malignant Melanoma
Hilal NALCIa, A. Kaan GÜNDÜZa, Feyza Tüntaş BİLENa, S. Kenan KÖSEb, Batuhan BAKIRARARb
aGöz Hastalıkları AD,
bBiyoistatistik AD, Ankara Üniversitesi Tıp Fakültesi, Ankara
Turkiye Klinikleri J Ophthalmol. 2018;27(2):114-22
doi: 10.5336/ophthal.2017-56132
Article Language: TR
Full Text
ÖZET
 Amaç: Konjonktiva malign melanomlu (Konj MM) hastalarımızda tedavi sonuçlarının Amerikan Kanser Ortak Komitesi ''American Joint Committee on Cancer (AJCC)'' klinik sınıflandırmasına göre değerlendirilmesidir. Gereç ve Yöntemler: Ankara Üniversitesi Tıp Fakültesi Göz Hastalıkları Ana Bilim Dalında Konj MM tanısı ile tedavi edilen 24 hasta AJCC sınıflaması sekizinci edisyona göre retrospektif olarak evrelendi. Primer tümör evresi T1 veya T2 olan hastalarda standart tedavi olarak total eksizyonel biyopsi (TEB)+kriyoterapi ve gerek duyulduğunda alkol epitelyektomi, yüzeyel sklerektomi ve amniyon membran transplantasyonu (AMT) uygulandı. T3 evre hastalarda ekzenterasyon uygulandı. Patolojide cerrahi sınırda tümör saptanması durumunda adjuvan tedavi olarak %0,04'lük topikal mitomisin C veya stronsiyum-90 brakiterapi uygulandı. Bulgular: Hastaların 14 (%58,3)'ü erkek, 10 (%41,7)'u kadın idi. Ortalama yaş 52,67±13,59 yıl saptandı. Ortalama izlem süresi 52,0±47,29 ay idi. Hastaların 12 (%50,0)'si T1a, 2 (%8,3)'si T1b, 4 (%16,7)'ü T2a, 1 (%4,2)'i T2b, 3 (%12,5)'ü T2c ve 2 (%8,3)'si T3c evredeydi. T1 ve T2 evrede TEB ve kriyoterapiye ek olarak 6 (%27,0) hastada AE, 1 (%4,5)'inde yüzeyel sklerektomi ve 4 (%18)'ünde geniş yüzey defekti nedeni ile AMT uygulandı. Evresi T3 olan 2 (%8,3) hastada primer ekzenterasyon yapıldı. On üç (%54,17) hastada ilk cerrahi sonrasında patoloji sonucuna göre cerrahi sınır pozitif idi. Bunların 8 (%61,5)'i evre T1, 5 (%38,5)'i evre T2 idi. Bunlardan 8 hastanın 7 (%87,5)'sine topikal mitomisin C, 1 (%12,5)'ine stronsiyum-90 brakiterapi uygulandı. İzlem boyunca 24 hastanınn 8 (%33,3)'inde nüks gelişti. Kaplan Meier analizine göre, tedavi sonrası nüks için sağkalım süresi T1 evrede 167,93±16,45, T2 evrede 45,07±21,71 ay idi. T3 evrede nüks görülmedi. Nüks gelişen 6 (%75) hastaya TEB ve krioterapi uygulandı. Bir hastada orbita tutulumu, 2 hastada ise yaygın ve forniksleri tutan tümör nedeni ile sekonder ekzenterasyon uygulandı. Beş (%20,8) hastada metastaz mevcuttu. Bunların 4 (%80)'ünde lenf nodu tutulumu görüldü. Sistemik metastaz bölgeleri bir hastada beyin, birinde akciğer, birinde akciğer ve sürrenal bez, birinde ise saçlı deri idi. Kaplan Meier analizine göre, tedavi sonrası metastaz için sağkalım süresi T1 evrede 187,27±15,95, T2 evrede 80,74±22,69, ve T3 evrede 9,00±2,12 ay idi. Dört hasta metastaz ile yaşıyordu. Bir hastada pankreas kanseri nedeni ile, birinde konj MM metastazı nedeni ile ölüm görüldü. Diğer hastalar izlem süresi sonunda hastalıkla yaşamakta idi. Sonuç: Konj MM'lerde AJCC klinik sınıflandırmasına göre T2 grubu, benzer göz koruyucu tedavilerin uygulandığı T1 grubuna göre daha yüksek nüks riski taşımaktadır. Bu hastalarda daha yakın izlem ve adjuvan tedavi önerilebilmektedir. Metastaz, T2 ve T3 tümörlerde T1 grubuna göre daha sık görülmektedir.

Anahtar Kelimeler: AJCC; konjonktiva malign melanomu; metastaz; nüks; prognoz
ABSTRACT
 Objective: To evaluate the treatment results according to American Joint Committee on Cancer clinical staging system in conjunctival malignant melanoma (conj MM). Material and Methods: Twenty four patients who were diagnosed with conj MM at Ankara University Faculty of Medicine, Ophthalmology Department were staged retrospectively according to AJCC 8th edition. Cases with T1 or T2 tumor stage underwent total excisional biopsy (TEB)+ cryotherapy. Alcohol epitheliectomy (AE), superficial sclerectomy (SS) and amniotic membrane transplantation (AMT) were performed as needed. T3 cases underwent exenteration. Adjuvant therapy with 0.04% mitomycin C (MMC) or strontium-90 brachytherapy were performed in cases with positive tumor borders in pathology reports. Results: Fourteen (58.3%) cases were males and 10 (41.7%) were females. Mean patient age was 52.67±13.59 years. Mean follow up time was 52.0±47.29 months. Tumor stage was T1a in 12 (50.0%), T1b in 2 (8.3%), T2a in 4 (16.7%), T2b in 1 (4.2%), T2c in 3 (12.5%), and T3c in 2 (8.3%) of the cases. For T1 and T2 stages, in addition to TEB and cryotherapy, AE was performed in 6 cases (27.0%), SS was performed in 1 (4.5%), and AMT due to large conjunctival defect in 4 (18%) of the cases. Two (8.3%) T3 cases underwent primary exenteration. Positive surgical margins were observed in 13 (54.17%) of the pathology reports. Eight (61.5%) of 24 cases with tumor positive borders were stage T1 and 5 (38.5%) were stage T2. Adjuvant topical MMC was used in 7 (87.5%), and Str-90 in 1 (12.5%) of the 8 cases with tumor-posive borders. During the follow-up recurrence was seen in 8 (33.3%) of the cases. According to the Kaplan Meier analysis recurrence-free survival was 167.93±16.45 monthss for stage T1, and 45.07±21.71 for stage T2. No recurrence was noted in T3 cases. Six (75%) of the recurrent cases underwent TEB+cryotherapy. Secondary exenteration was performed due to orbital involvement in 1 recurrent case, and due to diffuse fornicial involvement in 2 recurrent cases. Metastasis occured in 5 (20.8%) of the cases. Lymph node involvement was present in 4 (80%) of the metastatic cases. Systemic metastasis involved the lung in 1 case, lung and adrenal glands in 1 case, skin in 1 case and brain in 1 case. Metastasis-free survival time in T1, T2, and T3 cases was 187±15.95, 80.74±22.69, and 9.00±2.12 months respectively. One case died due to metastasis of conj MM, 1 patient died due to pancreatic cancer. Other cases were alive at the end of folow-up either with or without metastasis. Conclusion: AJCC stage T2 conj MMs carry a higher risk of recurrence compared to T1 cases which undergo similar eye-saving procedures. Close follow-up and adjuvant therapies may be offered in stage T2 cases. Metastasis is seen more frequently in T2 and T3 stages compared to T1.

Keywords: AJCC; conjunctival malignant melanoma; metastasis; recurrence; prognosis

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